EX-4.1



 Exhibit 4.1 
  

			
	 COMMON STOCK
	  	COMMON STOCK
	 CERTIFICATE NO. CS-    
	  	                     (    ) SHARE(S)

 ICC HOLDINGS, INC. 

ORGANIZED UNDER THE LAWS OF THE COMMONWEALTH OF PENNSYLVANIA 

 
  

 

			
	
is the owner of:              
                                         
 
	  	             
             (                    ) SHARES OF


 FULLY PAID AND NONASSESSABLE SHARES OF COMMON STOCK PAR VALUE $0.01 

PER SHARE OF ICC HOLDINGS, INC. 

a Pennsylvania business corporation. 

The shares represented by this certificate are transferable only on the stock transfer books of ICC Holdings, Inc. (the “Company”)
by the holder of record hereof, or by his duly authorized attorney or legal representative, upon the surrender of this certificate properly endorsed. This certificate and the shares represented hereby are issued and shall be held subject to all the
provisions contained in the Company’s official corporate papers filed with the Department of State of the Commonwealth of Pennsylvania (copies of which are on file at the principal office of the Company), to all of the provisions the holder by
acceptance hereof, assents. 
 IN WITNESS WHEREOF, FACILITY MANAGEMENT CORP. has caused this certificate to be executed by the
signatures of its duly authorized officers and has caused its corporate seal to be hereunto affixed. 
 Dated:     

 
  

 

											
	  
	 		 		 		  	  
	  	
	President	 		 		 		  	Secretary	  	








 ICC HOLDINGS, INC. 

The shares represented by this certificate are subject to certain limitations contained in the articles of incorporation (the “Articles”). A copy of
the Articles is on file at the principal offices of the Company. 
  
  

 
 The following abbreviations, when used in the
inscription on the face of this certificate, shall be construed as though they were written out in full according to applicable laws or regulations: 
  

							
	 TEN COM -
	  	 as tenants in common
	  	
UNIF GIFTS MIN ACT -     
                
	  	
custodian                 
   

		  		  	(Cust)    	  	
                  
(Minor)

			
	 TEN ENT -
	  	 as tenants by the entireties
	  	under Uniform Gifts to Minors Act
		  		  	                                 
       
		  		  	(State)
		  		  		  	
	 JT TEN -
	  	as joint tenants with right of survivorship and not as tenants in common	  		  	

 Additional abbreviations may also be used though not in the above list. 

For value received                      hereby
sell, assign and transfer unto 
 PLEASE INSERT SOCIAL SECURITY OR OTHER IDENTIFICATION NUMBER OF ASSIGNEE 

 
  

Please print or typewrite name and address including postal zip code of assignee. 

                         
                                         
                                         
  shares of the common stock represented by this certificate and do hereby irrevocably constitute and appoint
                                         
                                         
                                      , attorney, to
transfer the said stock on the books of the within-named bank with full power of substitution in the premises. 
  

							
	DATED
                                    	  		 	  

		  		 	 NOTICE: The signature to this assignment must correspond with the name as written upon the face of the certificate in every
particular without alteration or enlargement or any change whatever.

			
	SIGNATURE GUARANTEED:	  	  
	  	
		  	 THE SIGNATURE(S) SHOULD BE

GUARANTEED BY AN ELIGIBLE GUARANTOR

INSTITUTION